A nurse is caring for a client who is 3 days postoperative following open heart surgery and will be transferred to the medical-surgical unit. Which of the following information should the nurse plan to include in the verbal report?
The client's dressing change schedule.
The client's level of consciousness.
The client's vital signs from the previous shift.
The client's occupation.
The Correct Answer is B
Choice A rationale:
The nurse should not include the client's dressing change schedule in the verbal report when transferring care to the medical-surgical unit. While this information is important for the client's care, it is not a priority for the receiving unit to know during the immediate transfer. Dressing change schedules can vary based on the type of surgery and wound healing progress, and the medical-surgical unit will focus on the client's overall condition.
Choice B rationale:
The client's level of consciousness is a critical piece of information to include in the verbal report when transferring care. Changes in level of consciousness can indicate neurological deterioration or potential complications, especially after a major surgery like open heart surgery. This information helps the receiving nurses monitor the client's condition closely and respond appropriately if any deterioration occurs.
Choice C rationale:
While reporting the client's vital signs from the previous shift is important, it might not be the most relevant information during the immediate transfer from the postoperative unit to the medical-surgical unit. Vital signs can change rapidly, and the receiving nurses will assess the client's current vital signs upon arrival. Therefore, this information is not the priority for the verbal report.
Choice D rationale:
The client's occupation is not a critical piece of information to include in the verbal report during a transfer from the postoperative unit to the medical-surgical unit. The primary focus of the transfer report should be on the client's immediate postoperative condition, potential complications, and any other information directly related to their current medical status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Providing the client with information about advance directives is an appropriate intervention. Advance directives are legal documents that allow individuals to communicate their preferences for medical treatment in the event they become unable to make decisions for themselves. Educating the client about the importance and benefits of advance directives empowers them to make informed decisions about their care.
Choice B rationale:
Encouraging the client to contact an attorney to create advance directives is not the primary responsibility of the hospice nurse. While legal assistance might be helpful, the nurse should first ensure that the client understands the concept of advance directives and their significance before suggesting legal involvement.
Choice C rationale:
Informing the client that they will need a relative to witness their advance directives is not accurate. While witnesses are often required when signing legal documents, the specific requirements for advance directives can vary by jurisdiction. It's important for the nurse to provide accurate information and not make assumptions about legal processes.
Choice D rationale:
Telling the client that The Joint Commission requires clients to have advance directives is not accurate. While The Joint Commission emphasizes the importance of patient rights and informed decision-making, it does not mandate that all clients must have advance directives. The decision to create advance directives is a personal choice and should be based on the individual's values and preferences.
Correct Answer is A
Explanation
The correct answer is choice A: Provide information about alternate birth control methods.
Choice A rationale:
The nurse should prioritize providing information about alternate birth control methods to the client who is uncertain about undergoing a tubal ligation. This approach aligns with the principle of informed consent and patient autonomy. By presenting different options, the client can make a well-informed decision about their reproductive health. This ensures that the client's choice is based on a comprehensive understanding of all available alternatives.
Choice B rationale:
While involving the client's partner in the decision-making process can be important, the primary responsibility of decision-making lies with the client. Therefore, asking if the client has discussed the decision with their partner (Choice B) may not directly address the client's uncertainty and need for information about alternative birth control methods.
Choice C rationale:
Emphasizing the benefits of having the procedure (Choice C) might not be appropriate if the client is uncertain about whether it's the right choice for them. This approach may come across as biased and not respectful of the client's ambivalence. Providing unbiased information about all options is a more balanced approach.
Choice D rationale:
Discussing the client's feelings about the procedure (Choice D) is essential but should be done in conjunction with providing information about alternate birth control methods. Addressing the client's emotions without offering alternatives may not fully support the client's decision-making process.
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